Advanced Reproductive Specialists

03/19/2026

Endometriosis is truly a debilitating disease for many and it may present in several different ways. As a physician, it is truly frustrating that women are dealing with pain for years upon years without a diagnosis. It impacts everything - school/work/relationships... the list unfortunately goes on.

Most women with endometriosis have completely normal findings on ultrasounds, CT scans and MRI. That being said, their lives have been negatively impacted by something that is under diagnosed. As a matter of fact, women are passed from doctor to doctor, usually initiated on birth control pills and instructed to take some NSAIDs. The disease unfortunately progresses.

Our patients are diagnosed by a combination of "listening" to the symptoms and utilizing very basic testing. Our diagnostic accuracy is extremely high. As physicians, we learn that many times we can make the diagnosis simply by listening to a patient tell their story and I can't tell you how true that really is!

Endometriosis should be treated like cancer in that it should be excised. Our philosophy is that wide, peritoneal excision is the only way endometriosis should be treated. In the same way that a cancer surgeon attempts to excise all evidence of disease, both visible and microscopic, so should the endometriosis surgeon excise endometriosis. We feel that women that have multiple surgeries for endometriosis when it is cauterized is due to the persistence of lesions that are missed or not fully treated.

One of the comments highlighted the fact that hysterectomy is not the treatment for endometriosis and I couldn't agree more. Although it is an effective treatment for adenomyosis, it does not manage the endometriosis. Women that have both conditions may have persistent pain after a hysterectomy. It is essential to excise the endometriosis at the time of hysterectomy. Other more conservative ways to manage adenomyosis are available including presacral neurectomy which is a great option for many that desire to have a family in the future.

The last thing I would like to mention is the impact of endometriosis on fertility. Many believe it is due to scarring and problems with the fallopian tubes. In actuality, most women with endometriosis have open tubes. The condition causes a significant inflammatory reaction that can influence egg quality, endometrial (uterine) receptivity, and more importantly, egg reserve. We have performed several studies highlighting the fact that endometriosis is associated with diminished ovarian reserve. Since women are born with all of the eggs they will ever have, losing them at a more accelerated rate can significantly hinder ones ability to build a family. We perform ovarian reserve testing on women that have endometriosis to provide them with information for the future. When should I start to try for a family? How long should we wait between children? If I don't want to have a child now, is there something I can do to preserve fertility? These are questions that I help women find the answers to everyday. Endometriosis may pose many struggles - debilitating pain, hormonal implications, fertility issues or a combination thereof. As a physician, we need to be able to provide an effective plan for each.



Christopher W. Lipari, M.D.
Reproductive Endocrinology and Infertility
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine
JCRM.org

https://signalhfx.ca/halifax-doctor-agrees-endometriosis-should-be-treated-like-cancer/?fbclid=IwAR0FVU1ba6zIhhcWM36cq9M_ogmGXzpnoodtdaPfOolKbsA0adgkionnjS8 #.XkazbuYEsKI.twitter

This article is more than 6 years old. Halifax doctor agrees endometriosis should be treated like cancer New study published in Canadian medical journal says endometriosis patients should be taken more seriously Feb. 14, 2020 | 10:00 a.m. By Lesli Tathum 5 min read caption Photo illustration of some...

03/15/2026

Approximately 85% of couples achieve a pregnancy within one year of regular unprotected in*******se. This means about 12-15% of couples seek some form of fertility treatment at some point during their lifetime.

If you fall into any of these categories, call for an evaluation:

Women
• Age 35 and under who have been trying to conceive for 1 year without success
• Over the age of 35 who have been trying to conceive for 6 months without success
• Who have irregular periods or an absence of periods
• Who have other known problems that may affect fertility; ovulation problems, fibroids, endometriosis, blocked fallopian tubes, history of pelvic or abdominal surgeries or sexually transmitted infections

• Who have successfully become pregnant in the past, but are now unable to achieve a pregnancy

• Who have had multiple miscarriages

• Who desire to electively preserve their fertility

• Who know they will be having chemotherapy, radiation, an/or pelvic surgery due to a cancer diagnosis and want to preserve their fertility for the future

Men
• With an abnormal semen analysis

• With hormonal abnormalities; varicocele, a blockage, or absence of the duct that transports s***m from the duct, and/or difficulty with ej*******on

• Who have undergone a vasectomy

• Who know they will be having chemotherapy, radiation, and/or pelvic surgery due to a cancer diagnosis and want to preserve their fertility for the future

We understand how a diagnosis of subfertility is extremely anxiety provoking and stressful.
At ARS/JCRM, we have extensive experience, not only with diagnosing and the surgical/medical management of subfertility, but also in managing the stress that this diagnosis may bring. We take a comprehensive approach that provides a couple with all possible treatment options. You have a choice and it should be a well-informed and knowledgeable one, made only after understanding the underlying diagnosis and individualized fertility paths that are available to you.

Please call our office to schedule an appointment.

Should I See a Fertility Specialist? Approximately 85% of couples achieve a pregnancy within one year of regular unprotected in*******se. This means about 12-15% of couples seek some form of fertility treatment at some point during their lifetime. If you fall into any of these categories, call JCRM....

03/14/2026

Uterine Fibroids

​Uterine fibroids (also known as leiomyomas) are extremely common muscle tumors (or growths) that develop from a single muscle cell within the womb. It is stated in the literature that up to 75% of women develop a fibroid prior to menopause (1). That being said, not all women require intervention. The questions that need to be answered include: Do I really need this fibroid removed? If it needs to be removed, how can that be accomplished?

​Recommendations for fibroid removal or myomectomy hinge on size, location, symptoms and the desire for future fertility. Fibroids may be located anywhere in the uterus. Tumors located within or close to the uterine cavity may impact bleeding and cramping even if they are small. Some women may suffer from anemia or low blood counts. Larger fibroids can cause pressure symptoms and discomfort. Decisions regarding management in these cases are fairly straightforward since surgery should be able to resolve or significantly improve these symptoms. The big question is a woman with no symptoms that is attempting to conceive.

​It is well known that any fibroid that distorts or disrupts the uterine cavity has a negative impact on one’s ability to conceive both naturally and with in vitro fertilization (IVF) (2). In addition, pregnancy complications may be increased including miscarriage, preterm labor/delivery, postpartum bleeding, C-section risk and malpresentation (where the baby is positioned differently in the uterus). Some controversy exists regarding fibroids that are “close to” but not within the uterine cavity. According to multiple studies, there is some evidence that fibroids that exist in close proximity to the cavity (where the baby will be developing) do pose a negative impact on success. A recent study published in March of this year found that fibroids located close to the uterine cavity were associated with reductions in live birth rates in women undergoing IVF (3). How then do fibroids impact fertility?

​Fibroids that impact the uterine cavity have an obvious mechanical impact but what about fibroids not immediately within the cavity. What other mechanisms have been proposed? Impacts on blood flow have been proposed as well as the potential for fibroids to produce substances that may have a significant impact on the receptive nature of the nearby endometrium or uterine lining (4). Other theories have focused on the impact on the fallopian tube and the possible deleterious effect on the tubal transport of the s***m, egg or embryo. It is our belief that fibroids causing cavity distortion or larger fibroids in close proximity to the cavity should be removed.

​Since fibroid size and location are the most important characteristics that dictate how we counsel our patients, we recommend uterine imaging to assist us in our ability to recommend the best course of action. Saline ultrasound offers excellent visualization of uterine fibroids and furthermore, allows the physician to determine distance from the cavity as well as the best surgical approach for smaller fibroids that may not be directly visible from the outside when performing minimally invasive surgery.

​The technique of myomectomy may be performed in several different ways, depending on fibroid size, number and patient characteristics. Smaller fibroids located within the uterine cavity may be approached with a hysteroscope (an instrument placed through the cervix) while the patient is under anesthesia. This technique does not require incisions and most patients return to normal activity the following day. Larger fibroids or fibroids where all or the majority of the tumor is located outside the cavity are treated either with laparoscopy (small incisions) with approximately 5-7 days out of work or with laparotomy which requires longer recovery times. By far, the majority of cases can be handled in a minimally invasive way without a hospital stay. Laparoscopic management requires advanced laparoscopic skills and has been shown to be associated with reductions in post-operative complications and blood loss. Our experience has been that patients undergoing laparoscopic myomectomy recover faster and return to work sooner with minimal scars.

​Although fibroids are very common, the first step is to determine whether an intervention is necessary. This is based on symptoms and fertility desires. Furthermore, your physician, through very basic testing, can determine whether the fibroid(s) are hindering your ability to conceive and carry a child. If one desires to proceed with myomectomy, most can be accomplished in a minimally invasive way. We would encourage anyone with symptoms of painful periods, cramping, pelvic pressure or infertility to seek an evaluation for anatomic causes. There are multiple options available and outcomes after myomectomy are excellent.

Christopher W. Lipari, M.D.
Board Certified Reproductive Endocrinologist and Infertility Specialist
Jacksonville Center for Reproductive Medicine



1. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188: 100-7.
2. Farhi J, Ashkenazi J, Feldberg D, Dicker D, Orvieto R, Ben Rafael Z. Effect of uterine leiomyomata on the results of in-vitro fertilisation treatment. Hum Reprod 1995; 10: 2576-8.
3. Yan L, Yuq Zang Y, Guo Z, Lee Z, Niu J, Ma J. Effect of type 3 intramural fibroids on endometrial fertilization – intracytoplasmic s***m injection outcomes as: a retrospective cohort study. Fertil Steril 2018; 109: 817-22.
4. Rackow B, Taylor HS. Submucosal uterine leiomyomas have a global effect on molecular determinates of endometrial receptivity. Fertil Steril 2010; 93: 2027-34.

​Uterine fibroids (also known as leiomyomas) are extremely common muscle tumors (or growths) that develop from a single muscle cell within the womb. It is stated in the literature that up to 75% of women develop a fibroid prior to menopause (1). That being said, not all women require intervention....

03/12/2026

Adenomyosis is a condition in which the lining of the uterus appears to grow within the muscle of the uterus (myometrium). The term utilized in the past was "endometriosis interna" due to location of this tissue within the myometrium. The only way to diagnose adenomyosis with absolute certainty would be through pathologic confirmation (where a physician inspects the tissue with a microscope). This condition is very common and usually presents in the mid 30's but can be present at other times. Symptoms consist of heavy, painful cycles so many women and physicians may overlook it during the treatment of endometriosis. There are certain changes on imaging such as ultrasound in conjunction with a thorough history and exam that allow us to increase our clinical suspicion. We feel confident that we are able to predict its presence. Many times adenomyosis is diffuse, however, it can also appear similar to a fibroid when it is consolidated in one area. We evaluate women for both endometriosis and adenomyosis because it is extremely important to treat both conditions in women electing to proceed with surgical intervention. Although hysterectomy has been the treatment many have recommended in the past for the management of adenomyosis, it is not an option for women desiring to retain their ability to have children. We have had great success with peritoneal excision of endometriosis and pre sacral neurectomy, a procedure designed to "interrupt" one of the pathways for pain transmission from the uterus. It has allowed many women to proceed with building their family without struggling with pain from month to month. Other medical therapies have included continuous birth control pills or an IUD when not contraindicated; of course, these options are not useful in women while attempting to conceive.

Christopher W. Lipari, M.D.
Reproductive Endocrinology and Infertility
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine

03/10/2026

I get questions every day regarding endometriosis recurring in the future. Also, a common question is "will the disease pop up in other organs and locations in the body." I think we need to go back to: Where does endometriosis come from. While the prevailing opinion is Sampson's theory or retrograde menstruation meaning the menstrual flow goes backwards through the tubes. Under this theory, the living cells land on the peritoneum and then begin to grow. Based on my experience / opinion, and I think the majority of the Excision surgeons nationally, this can't be true for many reasons. My belief is a person is born with changes in the embryonic cell placement of endometrial cells (outside the uterus) and later the pubertal hormones activate the development of the endometrial cell cluster of endometriosis. If one focuses on this theory, then once excised or completely destroyed in any way, that endometriosis lesion is not coming back and because birth was the start, there will be no "new disease" popping up anywhere else.

Another myth that should be addressed here is spreading or invading. In all my years of doing surgery for endometriosis, I have never felt that the disease invades a tissue. The lesion can grow in size (with limitations) and the fibrosis can cause decreased blood flow compromising adjacent tissues such as bowel or bladder resulting in wall breakdown and the lesion ending up inside the bladder or bowel cavity. This is extremely unusual, therefore disproving any sort of primary invasion. In addition, I have never seen evidence of spreading or seeding like cancer in a metastatic way. The lesions they are born with are the ones they live with throughout their life unless excised and they don't multiply like weeds! Hope this clears some of the mystery as patients repeatedly ask these questions. Those that experience "recurrence" with ablation really have persistence as the lesions were not successfully eradicated with the prior surgery(ies).

Michael D. Fox, MD
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine
jcrm.org

03/08/2026

Dr. Fox discussing endometriosis and hormones.

03/07/2026

Dr. Lipari discussing endometriosis.

03/05/2026

Dr. Fox discussing endometriosis.

03/04/2026

03/03/2026

Hormones and endometriosis are integrally related. This is not discussed anywhere in the literature, textbooks and certainly not taught to upcoming OB/GYN residents currently in training. This is also true of Minimally Invasive Surgery Fellowships. As Reproductive Endocrinologists, we are innately attuned to Hormonal complaints from our patients. Observing through years of taking care of endometriosis patients, it is evident that estrogen levels begin to fall on average around age 35 producing intense symptoms to include a characteristic PMS syndrome of mood changes, bloating and cyclic headaches. In addition, all of the more typical symptoms of menopause can be evident as well. These symptoms include hot flashes, night sweats, night time urination, frequent urination urgency, vaginal dryness, Brain fog, anxiety, depression, memory loss, attention deficit disorder, bone pain and sleep disturbances just to name a few. Many women are all too familiar with these symptoms. In women without endometriosis, these symptoms would be common starting in the 43-45 age range and would be recognized by some doctors as pre-menopausal. At 30 or 35 however, nobody is thinking about menopause or estrogen, Sadly, most of these patients are placed on Anxiety, Depression, ADD, and Headache medicines and many are on all 4 when we see them. Most are so devastated by these symptoms and the relief provided by the drugs, that they can't conceive of coming off even after estrogen has resolved their symptoms. The low estrogen is caused by premature aging of the ovaries due to endometriosis induced chronic pelvic inflammation. If you know anyone with these symptoms, they need to be carefully evaluated for diminished ovarian reserve and treated appropriately. Remember, many women with endometriosis have little or no pain and are shocked when we suggest the diagnosis. There are other reasons for low estrogen as well and our world today brings estrogen down in many women who thrive via estrogen supplementation.

Michael D. Fox, MD
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine

Hormones and endometriosis are integrally related. This is not discussed anywhere in the literature, textbooks, and certainly not taught to upcoming OB/GYN residents currently in training. This is also true of Minimally Invasive Surgery Fellowships. As Reproductive Endocrinologists, we are innately....

03/01/2026

Endometriosis is TREATABLE!

Endometriosis is one of the most misunderstood (and mistreated) diseases in Gynecology and maybe medicine in general. The following discussion aims to explain our professional experience with this disease over the last 20 years where we took a special interest in the disease and its management. Our perspective is very different than what is conventionally believed.

Our surgical treatment method is complete excision that still, even today, is very unusual. There are few gynecologists in the US that do extensive excision surgery for endometriosis. The reasons for this relates very much to history and the advent of laparoscopic technology. From 1900 – 1975, all surgery for endometriosis was through an open incision like that for a hysterectomy. The treatment technique, though, was excision. There are numerous studies during that time period that showed 80+ % long term success for pain relief. This is compared to many laparoscopic cautery studies where long term relief is much less than 50%. There were also many studies that demonstrated an increase in fertility after excision treatment.

Recurrence: In contrast to what patients read on the internet, or told by physicians, endometriosis is most likely NOT a recurrent disease. We have re-operated on many patients in 18 years for other reasons with rare findings of recurrent disease. Most, >99% of gynecologists in the US, use destructive methods at surgery (cautery and laser) in an attempt to “destroy” visible lesions. In most cases, there are numerous lesions present, making this spot treatment very difficult. Microscopic lesions can be missed, and the tissue changes color with cautery and it is impossible to know if the entire lesion has been destroyed, especially for deeper lesions. With excision, the entire area including all the lesions extending out to normal peritoneum is removed. If lesions are deep, we recognize it as we undermine the peritoneum and can completely remove it. We believe a person gets all the endometriosis they are going to have by the mid teens and from there lesions go through their life-cycle and if removed are gone forever. No new disease is forming. What has been observed though by other physicians over time is recurrent pain in patients with endometriosis and when re-operated after a prior cautery procedure, lesions are seen. We see this also in nearly all patients after cautery and laser procedures and there is disease present but it is obvious that some of the disease has been treated before, just not completely. The appropriate word therefore is persistence not recurrence. We therefore feel that excision is curative for endometriosis. Pain could recur but endometriosis would be an unlikely cause of the problem. Hence pain does not equal endometriosis.

Adenomyosis: Endometrial cells located in the muscle wall of the uterus. All patients with endometriosis probably have some degree of adenomyosis. The pain with endometriosis is probably most often characterized as pain with periods in the teen years. As the lesions begin to burn out in the 20’s, many patients report cycles becoming less painful. By the mid 30’s, many patients are again having increased pain with periods. This however, is most likely due to the slowly progressive problem of adenomyosis. Therefore, after excision of endometriosis, if pain with periods recurs it is likely adenomyosis. Adenomyosis is not visible at or treated by surgery except through hysterectomy. It is most commonly suspected when the uterus is enlarged on ultrasound. Continuous birth control suppression can slow the progression of this process.

Call our office to schedule a consultation.

Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine

02/28/2026

Occult or hidden Inguinal hernia as a cause of pelvic pain in women

Currently in the U.S., there are fewer than 5 programs considering or offering treatment for inguinal hernias as a cause of pelvic pain in women. These hernias are called hidden because they are not appreciated on exam, xray or even visible initially on laparoscopy. This is a clinical syndrome that is diagnosed solely based on history, with some findings on exam that relate to the location of pain. The diagnosis is confirmed with a special search or dissection into the inguinal region at laparoscopy and the treatment is administered at that time in the same way a traditional hernia is repaired. To further define this, while typical hernias are visible immediately at laparoscopy because of the prolapse of the peritoneum through the inguinal ring, with occult hernias, there is no prolapse of peritoneum in most cases and therefore would be “missed” in a standard laparoscopy. This is a large part of the confusion with this diagnosis.

Little research has been done or exists on this topic but the buzz words for the syndrome are “sports hernia” or “runner’s hernia.” Even so, less than 15 articles exist on this topic. Dr. Debra Metzger, a reproductive endocrinologist, was instrumental in developing this diagnosis and treatment approach back in the 1980’s and 90’s. She treated hundreds of patients with great success and promoted the procedure. Diagnosis and treatment of hernias, however, is done by general surgeons as an integral part of their specialty. The vast majority of General surgeons on a philisophical basis do not operate solely for pain without diagnostic findings. This certainly would be a prudent approach for traditional hernias where a bulge is usually appreciated. This approach though would exclude 90+ percent of the occult hernias that we see and treat. Gynecologists on the other hand have been operating for pain for over 100 years to diagnose and treat endometriosis. The idea of operating on pain without specific findings is therefore not at all foreign to us.
At ARS/JCRM, we have established a working relationship with some general surgeons who are open minded enough initially to work with us and now see the dramatic results in their patients. Other surgeons have been critical of the approach and universally would tell our patients that they do not have a hernia if the patient was evaluated by these physicians. This is not a criticism of them as surgeons, this is simply a very obscure description and we wouldn’t expect any physician to understand this without specific education. This syndrome is very common in association with endometriosis and about 30-40% of our pain surgeries include attention to this problem.

The History: Patients may report the following:
Lateral low quadrant pain (often, “my ovaries”) that is sharp and intermittent or constant

Radiates: Down the front of the leg / inner thigh / groin
Through or around to the back
Less commonly to the hip or up towards ribs
Pain is worse with in*******se, periods and with exercise or standing for a long time
The pain can be relieved by recumbent position
Often relieved some by pressing on the area
Generally worsens over time but may come and go.
A prior laparoscopy seems to be able to relieve this pain for 3-12months.
A common history is a patient who has had several laparoscopies for endometriosis followed by losing one o***y (the bad pain side) followed by hysterectomy only to continue with the same pain localized to the groin.
The Physical Exam:
Pain just above the crease of the leg to palpation.
Valsalva or straining can make the pain increase in some.
Pain on vaginal exam when directed toward the inguinal ring.
The exam findings are not subtle in the vast majority of cases.
*Few patients exhibit all of these symptoms. Most patients have several of these key elements.
Xrays: CT would almost never find this. MRI might see it in a minority of cases.

Dr. Michael Fox, MD
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine
www.JCRM.org

https://jcrm.org/occult-or-hidden-inguinal-hernia-as-a-cause-of-pelvic-pain-in-women/

Currently, in the U.S., there are fewer than five programs considering or offering treatment for inguinal hernias as a cause of pelvic pain in women. These hernias are called hidden because they are not appreciated on an exam, X-ray, or even visible initially on laparoscopy. This